Citalopram is not considered dangerous during pregnancy, but it does carry some small risks that need to be weighed against the very real risks of untreated depression. The American College of Obstetricians and Gynecologists (ACOG) states that “robust evidence has shown that SSRIs are safe in pregnancy and that most do not increase the risk of birth defects,” while also noting that stopping these medications during pregnancy carries its own dangers. The decision is not as simple as “safe” or “unsafe.” It depends on the severity of your depression, how you’ve responded to other treatments, and what happens to your mental health without medication.
The Risk of Stopping vs. Continuing
One of the most important numbers in this conversation is the relapse rate. In a study published in JAMA, 68% of women who discontinued their antidepressant during pregnancy experienced a depressive relapse, compared with 26% of women who stayed on their medication. That’s a fivefold increase in the likelihood of a major depressive episode during pregnancy.
Untreated depression during pregnancy is not a neutral outcome. It’s associated with poor prenatal care, inadequate nutrition, preterm birth, low birth weight, and difficulty bonding with the baby after delivery. Severe depression also increases the risk of postpartum depression. ACOG’s position is that “for pregnant people who need SSRIs, they are life-changing and lifesaving,” and that discontinuing them “can carry risks.”
Birth Defect Risk
The concern that most people search for is whether citalopram causes birth defects. A large study in the New England Journal of Medicine found that overall SSRI use in the first trimester was not significantly associated with heart defects, with an odds ratio of 1.2, meaning essentially no meaningful increase above the baseline risk. Some individual SSRIs have shown specific associations: paroxetine was linked to a type of heart defect, and sertraline to a rare abdominal wall defect. Citalopram was not singled out for either of these associations.
A meta-analysis looking at SSRIs as a class did find a statistically elevated risk of miscarriage, with an odds ratio of 1.87. That sounds alarming, but context matters. The baseline risk of miscarriage in the general population is roughly 10 to 20%, and an odds ratio of 1.87 does not double that number for every individual. It’s a signal that deserves attention, but it also has to be interpreted alongside the known harms of untreated depression, which itself increases miscarriage risk.
Effects in Late Pregnancy
Taking citalopram in the second half of pregnancy introduces two specific concerns: a slightly elevated risk of a lung condition in newborns and a short-lived withdrawal-like syndrome after birth.
Persistent pulmonary hypertension of the newborn (PPHN) is a condition where a baby’s blood circulation doesn’t adjust properly after delivery, making it harder to breathe. Among babies exposed to antidepressants after 20 weeks of pregnancy, PPHN occurred in about 3.3 per 1,000 births, compared to 1.3 per 1,000 in unexposed babies. The absolute risk increase is small: roughly 1 to 2 extra cases per 1,000 treated pregnancies. Researchers estimated that between 417 and 5,000 women would need to take antidepressants in late pregnancy to produce one additional case of PPHN. When the analysis was limited to SSRIs specifically, the association weakened further and was no longer statistically significant.
Neonatal adaptation syndrome is more common. About 30% of newborns exposed to SSRIs in the womb show some degree of adjustment symptoms after birth. These can include jitteriness, irritability, feeding difficulties, and disrupted sleep. In most cases symptoms are mild. A study of 60 SSRI-exposed newborns found 10 with mild symptoms and 8 with more noticeable symptoms. The peak typically hits within the first two days of life, and all abnormalities resolved within a few days. Hospitals generally monitor exposed newborns for at least 48 hours, and medication treatment for the baby is rarely needed.
Long-Term Effects on Child Development
This is the area with the most uncertainty. A study from the Norwegian Mother, Father and Child Cohort found that children exposed to citalopram or escitalopram during pregnancy had higher rates of ADHD diagnoses (7.5%) compared to unexposed children (2.9%). They also showed some delays in communication and motor skills in early childhood.
The complication is that this study could not fully separate the effects of the medication from the effects of the underlying depression. The researchers did not find any biological mechanism (specifically, changes in DNA methylation) that would explain a direct drug effect. Depression itself affects the prenatal environment through stress hormones, sleep disruption, and other pathways. Children of mothers with untreated depression also show developmental differences. When citalopram-exposed children were compared specifically to children whose mothers had unmedicated depression, the citalopram-exposed group actually had fewer ADHD symptoms at ages 1.5 and 5 years. This suggests that at least some of the increased risk seen in broader comparisons may be driven by the depression rather than the drug.
How Pregnancy Changes Drug Levels
Your body processes citalopram differently during pregnancy. Blood volume increases, kidney filtration speeds up, and the activity of certain liver enzymes shifts. A study tracking citalopram blood levels across pregnancy found that concentrations dropped compared to postpartum levels, particularly in women whose bodies metabolize the drug at an intermediate rate (about a 36% drop by 36 weeks). Women who are fast metabolizers saw a smaller decline of around 15 to 19%.
This means that some women may feel their medication becoming less effective as pregnancy progresses. If your depression symptoms worsen in the second or third trimester, it may not be a failure of the drug itself but rather lower blood levels. Your prescriber can check levels and adjust the dose accordingly.
Citalopram and Breastfeeding
Citalopram does pass into breast milk. The relative infant dose, a standard measure of how much medication a nursing baby receives, averages around 6% of the mother’s weight-adjusted dose, with a range of 2.5% to 9.4% across studies. A relative infant dose below 10% is generally considered compatible with breastfeeding.
Some nursing infants have shown minor side effects including drowsiness, fussiness, restless sleep, and irritability. Weight loss has also been reported. These effects are uncommon and typically mild, but worth watching for, especially in the early weeks when a newborn’s ability to process drugs is still maturing.
Making the Decision
There is no risk-free option here. Continuing citalopram carries small, measurable risks to the baby. Stopping it carries a 68% chance of depressive relapse, with all the downstream consequences that brings for both you and your pregnancy. For women with mild depression, non-drug approaches like therapy may be a reasonable alternative. For women with moderate to severe depression, especially those who have relapsed before, the balance of evidence generally favors continuing treatment.
The most useful framing is not “Is citalopram safe?” but “What combination of risks am I most comfortable with?” That calculation is different for every person, and it depends on your history, your current stability, and how well you’ve responded to citalopram specifically. Switching to a different SSRI solely because of pregnancy is not automatically safer and can introduce its own risks during the transition.